PCP post-discharge survey

Evaluating the implementation and impact of an opioid medication management program, in a hospital discharge setting, to reduce falls in older adults

Documents and Forms

Document Name Document Type
PCP post-discharge survey Form
PCP Post-discharge survey Attachment E4 PCP post discharge Questionnaire.docx Form
Attachment I4 PCP Post Discharge Survey Screen Print.pdf PCP Post-discharge survey- screenshots IC Document

Information Collection (IC) Details

IC Title:	PCP post-discharge survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	PCP Post-discharge survey	Attachment E4 PCP post discharge Questionnaire.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: Epidemiolgic Studies and Suveillance of Disease Problems	FR Citation: 51 FR 226

Number of Respondents: 50	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	4	4
Annual IC Cost Burden (Dollars)	265	265

Documents for IC

Title	Document	Date Uploaded
PCP Post-discharge survey- screenshots	Attachment I4 PCP Post Discharge Survey Screen Print.pdf	10/22/2019

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.